Clinics in Perinatology,June 2004, Vol 31(2) page 210Stanley GravenEarly neurosensory visualdevelopment of fetus and newborn.“It is a serious mistake to assume that theprinciples derived from careful animal studiesdo not apply to human infants.The risk of suppression or disruption ofneeded neuralprocesses ...
All mammals have set sequenceof behaviours at birth ………….……. All with asingle purpose : toBREASTFEED
After birth, events aredetermined …… by the neonatestimulating the mother!(Rosenblatt 1994)
Breast-feeding is “establishedthrough a set of mutual,complex sensory stimulationsin mother and child.”(Kjellmer & Winberg 1994)
The “habitat - niche” conceptHABITATDETERMINESBEHAVIOUR
The “habitat - niche” conceptBEHAVIOURENSURESBIOLOGICALNEEDS
Warming, feeding andprotection behaviours areintricately, inseparablylinked to the right place.(Alberts 1994)= NUTRITION PROGRAMME
In all mammals …….….. the newborn isresponsible forinitiatingbreastfeeding,not the mother !!
In all mammals …….….. the newborn isresponsible forinitiatingbreastfeeding,not the mother !!EXCEPT IN HUMAN ???
Sequence human newborn breast-feedingPre-requisite = habitathand to mouthtongue movesmouth moveseye focuses nipplecrawls to nipplelatches to nipplesuckles(Widstrom et al 1994)
“The newborn may appearhelpless, but displays animpressive and purposefulmotor activity which, withoutmaternal assistance, brings thebaby to the nipple.(Michelson et al 1996)
“The newborn may appearhelpless, butraises its own temperature,has a higher blood glucose,metabolic adaptation faster.(Widstrom 1987)
METABOLIC ADAPTATIONSSC started in the first20 minutes after birthSSC CotBlood glucose (1 hr) 3.17 2.56Base excess drop 3.4 1.8(Christenson 1992)
Warming,feeding andprotectionbehaviours areintricately, inseparablylinked to the right place.(Alberts 1994)
Animal literature does not talkabout mammalian lactation,it talks about mammalian birth.Ruin the birth – andthere is no lactationWith a good birth,lactation followsDiane Weissinger
PSN envisions a community thatembraces its mothers and babies, andvalues the uniqueopportunity at birthto impact the physical and emotionalwell-being of the newborn.
Target #1 for 2005:Report that 65% of infants areplaced and remain indirect skin to skin contactwith their mothersfor at least one hourduring the first 3 hours after birth.
Step 1 SKIN-TO-SKINContinuous skin contactThe newborn must be in the rightenvironment for the behaviours thatit is capable of to be expressed. Itrequires protection from stress andprovision of warmth.KMC provides the “maternal nest”1SSCIdeally this should be done on prematures AT BIRTH.However it can be done later, even with nasogastric tubeproviding expressed breast milk in the meantime
Step 2 and 3 OlfactoryThe first steps in sequencerequire smell of the nipplewhich may take longer inthe premature,and then the smelling of milk.Babies can identify smells andtastes from their time in theuterus in the mother’s milk!23Smell nippleSmell milk
45Step 4 TasteThis is re-inforcing the smell.Fullterm seems to skip this!Step 5 RootingThese are mouth movementsthe normal sequencedescribed in the full-terms.Here the prematurerequires help, with positionand “sipping”= feeling milk in mouthTaste milkRootingSipping
6Step 6 First suckling.Key step, builds on steps 1 to 5.Must be awake and alert.Alert period is maximal at birth,and lasts 45 - 90 minutes.If missed then, will require feeding,and several hours delay.AlertforSuckling
6Step 6 First suckling.Note difference suckling vs sucking!“ … myographically distinct”For late premature lactation, allowsuckling to develop in successivealert periods, while feeding by tube.AlertforSuckling
From 16 or 20 weeks gestation,the fetus is swallowing.From 26 or 28 weeks gestationthe fetus can SUCKLEFrom 36 weeks gestation thefetus is able to SUCKSUCKING and SUCKLINGsound same, but VERY differentBreastfeeding & Suckling
7Step 7 Latching & swallowingPremature is too physicallyweak to crawl to nipple,but if held to nipple will atthis stage latch on.Once latched, suckling follows.Suckling squirts acontrolled dose of milkto the back of throat, whichis safely swallowed without anyinterference of breathingThis is INNATE.LatchingSwallowing
8Breast mealStep 8 First breast milk meal.Steps 1 to 7 and on take placerapidly in the fullterm.They can occur in the firstalert period after birth in apremature if allowed to,butmay require a longer periodof defined steps in successivealert periods. For late premlactation, step 8 is the firsttime milk is swallowedEnough to feed the baby.
910Frequent feedingTogethercontinuouslyStep 9 Frequent feedingIn utero, baby is feedingContinuously.Demand feedingis NOT SUITABLE for prematures.Feeds should be atmost 2 hours apart.Step 10Together continuously
The wheelis notroundTurnsslow atfirstbutthenpicksup speed!
THE NEWBORNalso has a larynx that meets theuvula, designed to separate therespiratory tract from thegastrointestinal tract ,enabling the newborn to feedand breathe simultaneously.
BottleBreastBaselinepO2BaselinepO2Start feed Ends feed 10 min laterSuckingburstRestTakes longerSucklingcontinuousNon-nutritiveSuckingburstMeier 1988BOTTLE AND BREASTFEEDING IN PREMATUREPrematures babies weighing 1300g and 34/40 PCA,given alternating bottle and breastfeeds.
(Chen et al 2000)25 babies in 80 sessions, all <1800g“There were 2 episodes of apnea and 20episodes of oxygen desaturation during bottle-feeding and none during breastfeeding.We conclude that breastfeeding is a morephysiological feeding method for the preterminfant and bottle-feeding may be morestressful.”BOTTLEFEEDINGIS STRESSFULand DANGEROUS
SUCKLING uses the largest muscle inthe baby’s head, makingthe smallest movementSUCKING requires lots of tiny andweak muscles, makingmaximum effort,… also causes hypoxia,… and is STRESSFUL !
Bottle feeding requires SUCKING,which requires completely differentmuscles, and does NOT allow co-ordination between swallowing andbreathing. Bottle feeding causes STRESS inprematures, and relative post-prandial hypoxaemia.SUCKLING - in and of itself,apart from nutrition intake -has beneficial effectson both mother and baby.SENSORY STIMULATION ....
Sucklinginduces simultaneous endocrineeffects in the gutof both mother and childthere is a physiologicalsymbiosis between them.Breast feeding also has psychic effects;CCK is produced,which induces sedation and sleep.
STATE ORGANISATION.The ability to appropriatelycontrol the level ofsleep and arousal.
Simplified scale -HARD CRYINGCRYINGFUSSINGACTIVE AWAKEQUIET AWAKEALERT INACTIVEDROWSYACTIVE SLEEPIRREGULAR SLEEPQUIET SLEEPDEEP SLEEPL to R shunting, IVH riskStressful, wastes calories,… build up to stressThis is feeding zone!Time to connect - stimulation… transition zone… transition zone… activity consumes caloriesGood sleep - digestion zoneApnoea zone !!STATE ORGANISATION.
SEESMum’s eyesHand TOUCHMum’s skinSkin-to-skinCONTACTSENSATIONS THAT WIRE BRAINBack FEELSMum’s armholdingTASTESMum’s milkEar HEARSMum’s voiceSMELLSMum’s milkWARMED onMum’s frontMOVESwith MumSlide from JILL BERGMAN
TRIGLYCERIDELeft : glycerol,Right: palmitic acid,oleic acid, alpha-linolenic acidIn phosphoglycerides,glycerol molecule same:two fatty acids esterifiedPhospholipids area major component of allbiological membranes,Sphingomyelin particularlyconcentrated in BRAINmajor part of MYELIN.
TRIGLYCERIDEMYELIN.Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year ....At one year: human milk has less protein,but MORE TRIGLYCERIDE !!!FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months,milk is 7.4% fat,but after 12 months it is 10.7%
CC homozygote for “FADS2”, “missing”NOT Brf DID Brf DID BrfNZ 98.4 103.2 98.9UK 97.3 104.0 100.7
Be sure the wet nurse has plenty of milk ...because if she lacks it she may give the babymilk of a goat or sheep or some other animal,because the child ... nourished on animal milkdoes not have perfect wits like one fed onwoman’s milk and always looks stupid andvacant and not right in the head.14th century Tuscan text
Human Milk Banking Associationof North America•Setting the Standards for Human Milk Banking•Meeting the Milk Banking Needs for North America•A Safe Alternative in the Absence of Infants Own MothersThis website is designed to provide information onmilk banking and how to contact a milk bank todonate milk or to order donor human milk. Thissite is also a resource for health care providers andothers who are looking for information onHMBANAs resources and services.http://www.hmbana.org/
"Where it is not possible for the biologicalmother to breastfeed, the first alternative, ifavailable, should be the use of human breastmilk from other sources. Human milk banksshould be made available in appropriatesituations."World Health Organization/UnitedNations Childrens Fundhttp://www.breastmilkproject.org/
INFANT FEEDING FREQUENCY:available evidence & neuroscienceReferences in this formatOVERVIEW:New section this backgroundNeuroscienceAnatomy & physiologyAvailable evidenceProposal feeding frequencyImplications85
"I have finally cum to the konklusionthat a good reliable set ov bowelsiz worth more to a manthan enny quantity of brains.“Josh Billingshttp://www.vivo.colostate.edu/hbooks/pathphys/digestion/stomach/anatomy.html
The digestive system is endowed with itsown, local nervous system referred to asthe enteric or intrinsic nervous system.The magnitude and complexity of the entericnervous system is immense - it contains asmany neurons as the spinal cord.ENTERIC NERVOUS SYSTEM !!88
Functional at end of first trimester,begins very early, experience dependent“effective from 29w GA” significantSMELL“Olfaction in the fetal andpremature infant:functional status andclinical implications”Benoist SCHAALENSANS BreastSensory environment :Intrusive(pain) SupportiveInternalSomaticenvironmentExpectedexternalenvironmentSchaal 2004 90
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviourSMELLSchaal 2004 91
DOUCETThe secretion of Areolar (Montgomery‟s) Glands fromLactating Women Elicits Selective, UnconditionalResponses in Neonates“… breast chemosignalsactivate oral activity on thenipple that releases a cascadeof behavioral, neural, neuroendocrineand endocrine processesin the newborn and the mother.”Doucet 2009 93
The secretion of Areolar(Montgomery‟s) Glands“In early ontogeny thesleeping brain may thusremain sentient of anorganism‟s odorenvironment.”Doucet 2009 94
Fetal stomach appears 4 weeks GA.By 11 weeks, wall capable of muscularcontraction.“Patterns of antropyloric motilityin fed healthy preterm infants”... the neuroregulatory mechanismsresponsible for the coordination of antro-pyloric motility and gastric emptying arewell developed by 30 weeks of PMA.Hassan 2002 97
Hydrochloric acidimportant for activation of pepsinogen,inactivation of microorganisms such as bacteria.Pepsinogenactivated by acid into active pepsin,responsible for the stomachs ability to initiatedigestion of proteins.Chymosinis an enzyme whose role is to curdle orcoagulate milk in the stomach, a process ofconsiderable importance in the very young animal.98
Chymosinmakes the milk into “cheese”halfway between liquid and solidstomach empties in 60 minutesmilk99
Gut hormones.20 different hormoneswork in the gut –regulated by the vagal nerve.Each has a specific function.Uvnas-Moberg 1989 100
Formula for calculation of stomach capacity (Charles Bradshaw, UCT)Assumptions: the stomach can be approximated by dividing intothree sections, namely a ellipsoidal hemisphere, an ellipsoidal cylinder,and a skewed ellipsoidal cone.Variables: a = anteroposterior radius, t = transverse radius, l = length stomachRelations: the height of the cone and the hemisphere are both the same as „a‟.Ellipsoid = 4/3 * Pi* r1*r2*r3 = 4/3 *Pi * a * a * t;therefore volume of hemisphere = 2/3 Pi * a *a * tCylinder = Area of base * height = (Pi * a * t ) * ( l - 2a )Skewed cone = 1/3 * base *height = 1/3 * Pi * a * t * aTotal volume = 2/3 * Pi *a*a*t + Pi * a * t * (l- 2a) + 1/3 * Pi * a * t * a=Pi a*t*l -Pi * a *a*t= Pi * a * t*(l-a)Goldstein and Sase data:Stomach capacity at term 10 - 15 mlBRADSHAW formula115
Assumption: 2,5 kg baby 33w GA,requiring 150 ml/kg/day = 375 ml45 MIN CYCLES ( 32 cycles/day)12 ML PER CYCLE = 384 ml116
Newborn stomach volume.Gastric volumes at birthCorrelated with gastric pH,gastrin and somatostatin “fetus drinks 10 ml portionsof amniotic fluid …”Widstrom 1988 117
Only recent study located:“Autopsy” capacity was determinedin Indian post-mortem studies100 autopsies (63 SB, 37 ENND)Tied at cardia and pylorus, filled withwater, emptied & measured, repeated,“… obliteration of the gastric curvatures”“due care to minimize stretch artifacts”Naveed 1992“An Autopsy Study of Relationship betweenPerinatal Stomach Capacity and Birth Weight.”118
Infants above 2500g only:Ave RangeStillborn (n 11) 19.6 ml (10-35)Early death (n 9) 17.8 ml (10-25)All cases (n 20) 18.8 mlNaveed 1992“An Autopsy Study of Relationship betweenPerinatal Stomach Capacity and Birth Weight.”119
120KERNESSUK 1997 (Russian)Postmortem: in situ measures(applied Bradshaw formula)AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data:Scammon and Doyle 1920Zuccarelli‟s method: stomach filled atautopsy to “a pressure of between15 and 20 centimeters of water”Scammon 1920“Observations of the capacity of the stomach inthe first ten days of post natal life.”121
Anatomic capacity was determinedin post-mortem studiesMain data set Alliot 1905 (n 25)Scammon own cases ? (n 13)30 – 35 ml at birth –almost regardless of birth weightScammon 1920“Observations of the capacity of the stomach inthe first ten days of post natal life.”122
Known references with data:Scammon and Doyle 1920quoted in Silverman 196114571 feeding records from 323 newborns“physiologic capacity” all breastfedtest weighing before and after feedingScammon 1920“Observations of the capacity of the stomach inthe first ten days of post natal life.”123
“… modern infant feeding.” “infants were breastfed 5 times per day”INFERENCE?? If fed 5 x per dayand daily requirement 160 ml x 3kg = 480Required volume: 480 / 5 = 96 mlsDid not measure stomach capacity:Pre-determined a feeding frequency!Scammon 1920 124
“… modern infant feeding.” 5 per dayDid not measure stomach capacity:Pre-determined a feeding frequency!“ … the figures … presented here aredistinctly higher than those of earlierinvestigators … not surprising considering… (they) made their observations uponinfants which were fed eight or moretimes per day.”Scammon 1920 125
Imagine a study !!Let us measure the stomach capacitywith a balloon ... at end of NGTTest the pressure on adultsmust not be uncomfortableOnce the pressure starts to rise: there is risk for reflux to be avoided – expected physiologyTHIS SHOULD BE THESTOMACH CAPACITY126
Imagined study was done!!Zangen S et al 2001Rapid Maturation of Gastric Relaxationin Newborn InfantsZangen 2001No reference given ....12775 ml per feeding
Zangen S et alRapid maturation of gastric relaxation in newbornsPressures (mmHg)Balloon inflates to15 ml no increasefunctionalcapacity128
TERMINOLOGY PROPOSALS“Functional capacity”equivalent to “expectation volume”,for which optimal pepsin / acid is made,does not cause distentionallows adequate time for curdleallows protein breakdownallows controlled pyloric passage129
Zangen S et alRapid maturation of gastric relaxation in newbornsPressures (mmHg)Balloon inflates to15 ml no increase20 ml pressure OKphysiologicalcapacity …. 130
TERMINOLOGY PROPOSALSPhysiological capacityMaximal amount stomach can handlewithout undue stress.“Receptive capacity” of STOMACHmaximal amount stretched organ holds“Ingestive capacity” of BABYamount baby or infant swallowed,(note, excess not in stomach) 131
Physiological capacityMaximal amount stomach can handlewithout undue stress.“Receptive capacity” of STOMACHmaximal amount stretched organ holds“Ingestive capacity” of BABYamount baby or infant swallowed,(note, excess not in stomach)Scammon and Doyle did draw attention to this also ....132
EVIDENCE: (NBn 111009)Author Capacity Note:Sase 10-15 ml Live, term fetusGoldstein 10-15 ml Live, term fetusWidstrom 10 mls Live, newbornZangen 20 mls Live, (pressure)Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water(Alliot) pressure)133
PROPOSAL:The CAPACITY of aweek old baby‟sstomach isapprox 20 ml.134
Zangen S et alRapid maturation of gastric relaxation in newbornsA balloon in stomachcan fill to 76 mlsWhat does thestomach –without a balloon –do to 76 mls?REFLUX !!!PRESUME: each feedapproximately 75 mlsZangen 2001 142
WHERE IS THE MILK?This volumeis not inthe stomachStomachStomachStomach143
WHERE IS THE MILK?Mother’s shoulderOesophagusDuodenumDuodenumStomachStomachStomachHow To Do Just AboutEverythingHow to Burp a BabyBurping a babycan reducespitting up andrelieve bloatingcaused byswallowed air.Here are sometried-and-truemethods.144
WHERE IS THE MILK?What happens when my babyspits up?Babies spit up when theyve eatentoo much or when theyre burped. Itcan also happen when your baby isdrooling.Spitting up is not vomiting.Spitting up is REFLUX.Nils Bergman, 2011146
Blood sugar may fall …after 90 minutes ...“There is areason behindeverythingin nature” AristotleWould nature allow this?147
Large volume feedsstretched stomach=doubled absorptivecapacity as adultStettler 2005Stettler et alWeight Gain in the First Week of Life and Overweight in Adulthood:A Cohort Study of European American Subjects Fed Infant Formula149
This finding is important,not so much to predictwhich infants are at riskfor becoming overweightadults, but more to under-stand the importance ofthe human physiologyof programming duringshort early-life periodson the development ofchronic disease over thelife course.Stettler et alWeight Gain in the First Week of Life and Overweight in Adulthood:A Cohort Study of European American Subjects Fed Infant Formula150